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.C s --'r• - a y -rs- —90 3.fw a �.a.. R• t< SwtS '�� .£.:r :- '` F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAVICES ALTH SER Telephone: (2��0pp9�)) 4[66- ��tICOUNI'Y-I'LL� '1SION PERMIT EXPIRES 1 YiEAfRFR A�ti1�3"UE� ICom p!etft in Tripticat i j-i PE Application is hereby made to the San Joaquin Lccal health District for a permit to construct and/or install the work herein described.This application is made in compllanCe with San Joaquin County Ordinance No.579 for sewage or No.IB62 for welllpu:np and the Rules and RegataFans of the San Joaquin Local Health District. ?f14K S:. [}trs7 tr••^ ,L�;tn`+ Job Address City Lot Size PM Owner's Name_�i�'tn- t�r7" tI 11r_ilt% Address �� :i• �31:�'e E+ 1' fi! Ph ( -.'l,'J) of�-35:7" c:+a Contwcfas 'Sc�CtT_•r' Address ^S':"' '1132 St„ Lt+;r.'i .j icense No. :SIN?'r.:r.l Phone f'7')�J?5-1 4 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ifn» h -•4 `l, r PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial C1 Open Bottom ❑Manteca Dia.of Well Excavation "' Dia.of Well Casing 'a ❑OomesticlPrivate a Gravel Pack ❑Tracy Type of Casing ,�, Specifications P1 Public n other!)tCT Delta Depth of Grout Seal Type of Grout_++�,••' ~ la,gaucim 0-:-r, Approx.Depth l!Eastern Surface Seal Installed by _ Repair Work Done L] Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter t Sealing Material(top SO') Depth r'' t Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence__ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT,❑ Method of Disposal �.P Distance to nearest: Well Foundation Property Line LEACHING LINE Ci No.&Length of lines Total iengihlsi e FILTER BED ❑ ,Distance to nearest: Well Foundation Property Lina SEEPAGE PITS. I I Depth Size Number SUMPS 0 Distance to nearest: WAI Foundation Property Line e DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signaiure certifies the(allowing:"I certify that in the performance of the work for whlah this pemil is issued,1 shall not r•s employ any person in such manner as to become subject to workman's compensation laws of California,"Contractors hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa• tion Paws of C Qrnia," J The applica s call for all re i inspections./Comr.,nteftlrawing on revs s , ! r0a1 �..; Signed � ..t C / ..• a.f/-f.� �r' �`• it � ;l % e: FOR DEPARTMENT USE ONLY Application ccepted by r yv//l Data y L ` Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: '�t ❑Slit 466-6781 ❑Lodi 369-3621 i r 0 Manteca a23-7144 ti ❑Tracy (335.6385 Applicant•Return all copies to:Environmental Health PermitIScevicas 1601 E. Hazelton Ave.,P.O.Box 2009,Stk.,CA 95241 FEE IN AMOUNT DUE AMOUNT REMITTED CASH CK 10 RECEIVED BY DATE PERMIT'NO. .Ex ty]I IAEv.t r s, EH t{le 0F C� fT OIIE DTO ITION OI' ' ORIGINAL ';